A 27yr old patient came with chief complaints of pedal Edema since 10 days

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.

CHIEF COMPLAINTS-

C/o loss of appetite since 20 days

C/o tremors since 15 days 

C/o blood in urine since 10 days and

C/o pedal edema since 10 days

HISTORY OF PRESENT ILLNESS-

Patient was apparently asymptomatic 20 days back then he had loss of appetite for which he went to the hospital and was diagnosed as CLD spleenomegaly and portal hypertension for which he  took medication after which he developed haematuria since 10 days and pedal Eden’s which is of pitting type. 

Pedal edema is relieved by taking test and increases on walking. He had developed tremors since 15 days and Malena 20days ago for 10 days. 

He complained of decreased sleep since 1 month.

No c/o abdominal pain, vomiting, loose stools,burning micturition.

HISTORY OF PAST ILLNESS- 

He had similar complaints in the past (1 yr ago)

Not a known case of DM, HTN, Epilepsy, TB, CVA, CAD.

SURGICAL HISTORY- 

H/o appendectomy 4 yrs back.

PERSONAL HISTORY-

Appetite- lost since 20 days

Non-vegetarian 

Bowels- regular

Micturition- haematuria since 10 days

Addictions-

Alcohol- regularly since the past 6 yrs. increased intake since last 2yrs. 1/2 bottle per day twice daily 

FAMILY HISTORY- 

Father is a chronic alcoholic.

PHYSICAL EXAMINATION- 

GENERAL EXAMINATION-

Pallor- No

Icterus- yes

Cyanosis-No

Clubbing- yes

Lymphadenopathy- No

Odema of feet- yes (grade 1)

Temperature-

Pulse rate- 90/ min

Respiration rate-

Blood pressure-100/60 mm hg 

GRBS-122%

SYSTEMIC EXAMINATION-

CVS-

Thrills- No

Cardiac sounds- s1s2 heard

Cardiac murmurs- No

RESPIRATORY SYSTEM-

Dyspnoea- No

Wheeze- No

Breath sounds -vesicular 

ABDOMEN-

Shape of abdomen- scaphoid

Tenderness- not present 

Palpable mass- not present

Free fluid- not present

Liver- not palpable

Spleen- not palpable 

CNS-

Level of consciousness- consciousness 

Speech- normal

INVESTIGATIONS-

HEMOGRAM

CUE

APTT

PROTHROMBIN TIME

BLOOD SUGAR- RANDOM

BLOOD UREA

SERUM CREATININE 

SERUM ELECTROLYTES AND SERUM CALCIUM 

LIVER FUNCTION TESTS

ULTRASOUND

 
PROVISIONAL DIAGNOSIS-DECOMPENSATED LIVER DISEASE - grade 1 ( hepatic encephalopathy)

HYPOTONIC HYPONATREMIA - diuretic induced.

TREATMENT-

Rx

IV fluids NS 75ml/hr 

Inj vitamin K 10 mg IV/OD

Inj Thiamine 200 mg IV/BD in 100 ml NS 

T Doxy 100 mg PO/BD

T Udiliv 300 mg PO/ BD 

T Viboliv 500 my PO/BD

Syp. Hepamerz PO/T/ID